Alcohol Withdrawal Seizures: occur as early as 6 hours after last drink, 90% occur in first 48 hrs. 40% only have 1 while 60% can have multiple. 85% will have their second seizure within 6 hours after the first one. Most can be discharged if treated appropriately, are uncomplicated, and have been observed for 3 hour period. 1/3 will go on to develop DTs. If seizures are partial, always get CT scan.

Alcohol Withdrawal Hallucinations: auditory/visual hallucinations without clouding of sensorium. Auditory more common. Usually at 12 hours.

Front: rapid admin of long acting until there is a significant improvement in symptoms. Can lead to over sedation, but permits self-tapering. Titrated to development of lid-lag (sleepy, but a rousable). Don’t titrate to HR. Thats the end goal.

Symptom trigger approach: 4mg lorazepam q1hr given each time CIWA-Ar > 8. More common, though front loading has more rapid resolution of symptoms, less need for additional medications, and less reliance on withdrawal scales.

Anticonvulsants promising, but not ready for prime-time. Carbamazepines / Valproate – studies show promise, somewhat hepatotoxic side effect. Oxcarbazepines – no better than placebo for withdrawal in limited studies. Gabapentin – data is scattered, likely related to dose. 1200-1600mg seems to be the better dose.

Dexmedetomidine (Precedex): centrally acting alpha agonist. Like IV clonidine. Results in sedation/decrease HR/BP, no anticonvulsant therapy. Should not be used as monotherapy bc of this. Still controversial.

Phenobarb: can use with mild withdrawal – lasts so long, don’t need to re-dose. Binds GABA receptors. Half-life 2-7 days. The problem with benzos is that they don’t last long enough. Usually need to give prescription before they’re discharged. For inpatients. give 10mg/kg over 30 minutes. Reduces ICU admissions. Outpatient: 260mg IV, then can get second or third dose of 130mg. No need for prescription after discharge.

Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar): structured score used for treating alcohol withdrawal. 10 domains of symptoms with scores of 0-7. Scores > 8 need medication. If the total score is below 10 after first dose of medicine, no further treatment recommended. Score Sheet Link.

Mild to moderate uncomplicated alcohol withdrawal responding well to initial ED tx can be discharged to detox unit or to supportive family with outpatient program referral. Ativan 2-4mg q4hrs x 5 days. Give CIWA sheet to family member and tell them to check every 6 hours – if >8, given dose. If not improving, have them bring them back in.

4 objectives: ensure safety of patient, staff, and others; help the patient manage emotions and distress; avoid use of restraints; avoid coercive interventions. AVOID restraints if you can.

De-escalation: respect personal space, do not be provacative, establish verbal contact, keep it concise and simple, identify wants/feelings, listen to what the patient is saying, agree or agree to disagree, set clear limits and establish acceptable behaviors, offer choices and optimism (option of taking medication), debrief the patient and the staff.

What Mediators Can Teach Physicians About Managing ‘Difficult’ Patients – The American Journal of Medicine, Editorial: view difficult patients as syndromes, not a species. Situation is volatile: escalation or de-escalation is seconds away, calling someone out for bad behavior makes matters worse, exercise neutrality, name the concern to create alliance and avoid adversity, apologize.

Medications

First generation: haloperidol & droperidol. Droperidol: recent annals article using 10mg with no complications. Haldol is black-box as well right now

IV Olanzapine (Zyprexa): as effective as IV halidol. Similiar history as FDA approved for IM, though not IV. Few studies, less SE compared to haldol. Start at 2.5mg-5mg, max daily dose of 20mg. Higher doses have higher risk of sedation. (Martel 2015)